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Grand Rounds: “I Think I Have Worms In My Eye”

Kevin Lowder, MD – PGY3 08/24/2018. Grand Rounds: “I Think I Have Worms In My Eye”. Patient Presentation. CC: “I think I have worms in my eye” HPI

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Grand Rounds: “I Think I Have Worms In My Eye”

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  1. Kevin Lowder, MD – PGY3 08/24/2018 Grand Rounds:“I Think I Have Worms In My Eye”

  2. Patient Presentation CC: “I think I have worms in my eye” HPI • 34 yo WF with PMH of non-ischemic cardiomyopathy p/w 2-3 weeks of acneiform skin lesions on her face, out of which she has been pulling what she believes are worms. • During that same time she describes a FBS in her right eye and says “I can feel a worm moving around in my right eye.” This coincides with blurry vision OD as well. No other ocular symptoms.

  3. Patient Presentation (continued) HPI (continued) • No history of trauma, travel or swimming in lakes/ponds/ stagnant water, etc. • No history of consuming raw/undercooked meat • Pt lives on a farm where there are animals, but works in an office setting • Pt believes her parent’s home uses well water

  4. Patient Presentation (continued) HPI (continued) • Multiple recent ER presentations: • 7/3/18 – dyspnea and syncope • 7/27/18 – skin lesions on face, neck, back & chest; general malaise (since visit on 7/3/18) • 8/3/18 – skin lesions, blurry vision OD, headache

  5. History (Hx) Past Ocular Hx: none Past Medical Hx: non-ischemic cardiomyopathy, chronic pain Fam Hx: Non-contributory Meds: Tramadol, Adderall Allergies: NKDA

  6. History (continued) Social Hx: denies EtOH, illicit drugs* or smoking RoS: Skin lesions, general malaise, headaches, diarrhea

  7. Physical Exam

  8. Anterior Exam

  9. Posterior Exam

  10. Work-Up: • OCT Macula: WNL OU • OCT Anterior segment OD:

  11. Assessment 34 yo WF with acneiform skin lesions +/- wormlike inclusions, clear cystic areas on the bulbar conjunctiva with blurry vision OD Differential Diagnosis • Non-Infectious: • LYMPHATIC MALFORMATIONS • Lymphangiectasia • Lymphangioma • LYMPHOPROLIFERATIVE DISORDERS (Unlikely) • Lymphoid hyperplasia • Lymphoma • OTHER: Neoplasia/Metastases/Amyloidoses (Unlikely) • Infectious (Unlikely) • Parasitic/helminthic infection

  12. Plan • CBC with differential & BMP  Normal • Diagnosis: • Non-Infectious: • LYMPHATIC MALFORMATIONS • Lymphangiectasia • Lymphangioma • LYMPHOPROLIFERATIVE DISORDERS • Lymphoid hyperplasia • Lymphoma • OTHER: Neoplasia/Metastases/Amyloidoses (Unlikely) • Infectious (Unlikely) • Parasitic/helminthic infection

  13. Lymphangiectasia • Irregularly dilated lymphatic channels in the bulbar conjunctiva, often associated with marked chemosis • May be developmental, or can occur following trauma or inflammation • Anomalous communication with a venule can lead to spontaneous filling with blood • *MUST DISTINGUISH THIS FROM ATAXIA-TELANGIECTASIA* • Treatment: Local excision or diathermy

  14. Lymphangiectasia

  15. Lymphangiectasia Haemorrhagica Ataxia Telangiectasia Photo courtesy of: https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1600-0420.2004.00291.x Photo courtesy of: http://www.wikiwand.com/en/Ataxia-telangiectasia

  16. But what about worms??

  17. Discussion

  18. Ocular Parasitic Disease • Toxoplasmosis • Toxocariasis • Cysticercosis • Onchocerciasis • Hydatid Cyst (Ecchinococcus) • Diffuse Unilateral Subacute Neuroretinitis • Gnathostomiasis • Ophthalmomyiasis • Dirofilaria • Ascariasis • Leishmaniasis • Pediatric Presumed Nematode • Malaria (Plasmodium) • Seasonal Hyperacute Panuveitis • Amoebiasis (Acanthamoeba) • Giardia

  19. Review Article – Important Points • Most of these infections are very uncommon (some are extremely rare) • Most are endemic to foreign countries/continents • Ocular parasitic infection leaves clues

  20. Ophthalmomyiasis?(Maggots from Diptera fly) From Duane’s Clinical Ophthalmology Volume 5 Chapter 33, Figure 42

  21. Dermatillomania?(skin picking disorder) Photo courtesy of: http://www.dailymail.co.uk/health/article-2636089/I-stop-scratching-face-Student-compulsive-disorder-means-spends-SIX-hours-day-picking-skin-bleeds.html

  22. Conclusions • Lymphangiectasia is a relatively common finding, and is often asymptomatic • If treatment is required, local excision or diathermy can be utilized • If it spontaneously bleeds from communicating with a venule, you must rule out Ataxia-Telangiectasia • It is quite easy to differentiate from parasitic infection

  23. References • 2017-2018 Basic Clinical Sciences Course, Section 8: External Disease and Cornea. American Academy of Ophthalmology, 2017. • 2017-2018 Basic Clinical Sciences Course, Section 9: Intraocular Inflammation and Uveitis. American Academy of Ophthalmology, 2017. • https://www.aao.org/bcscsnippetdetail.aspx?id=9da9385b-8c6b-466a-8f95-02416a14f434 • Das D, Ramachandra V, Islam S, et al. Update on pathology of ocular parasitic disease. Indian Journal of Ophthalmology. 2016;64(11):794-802. doi:10.4103/0301-4738.195590.

  24. Special Thanks • *Dr. Eiferman • *Dr. Scott

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